The Contagion Contingent

“We came from a place where infections were thought to be part and parcel of the healthcare course. There was a belief that some percentage of infections would occur and there was no way to prevent them,” said Dickey. “Fast forward 50 years where our goal is zero infections. While we recognize we will likely never live in a world without infections, and some germs are our friends, we do want to shoot for zero when it comes to pathogenic microbes that cause serious illness.”

While physicians, nurses, respiratory therapists and other healthcare staff members had always done what they could to prevent infections, APIC established the role of the infection preventionist (IP), someone solely focused on this critical area of healthcare delivery. Today, IPs employ evidence-based practices to keep patients safe from device-associated infections, surgical site infections (SSI) and other healthcare associated infections (HAI).

In honor of the IP profession, Healthcare Purchasing News presents its 2022 Infection Prevention Operations Worth Watching, highlighting U.S. health system and hospital IP teams that have demonstrated outstanding dedication, practices and successes in infection prevention.

A true team approach to IP in the time of COVID

The COVID-19 pandemic has complicated the work of IPs, with efforts now split between protecting patients and healthcare staff members from the SARS-CoV virus and the continued fight against HAIs. That is why this year’s list of IP success stories include efforts aimed at addressing both long-standing infection risks and the new challenges presented by COVID-19.  

“The pandemic has amplified and magnified the skill set needed to be an IP because you have to be very resilient and a team player who helps coordinate various stakeholders and move a lot of levers at the same time,” said Dickey. “You have to be able to multitask and keep your eye on several different priorities simultaneously.”

The IP Team members for Dartmouth-Hitchcock Medical Center in Lebanon, N.H. have played a vital role in the success of IP goals despite the challenges of the COVID-19 pandemic. At the same time, they have continued to strive for professional growth and development by earning graduate degrees, acquiring certification in Infection Control, participating in local and regional infection control chapters, webinars and conferences, and more.

Here’s how the IP team members have successfully executed on their specific responsibilities to drive improved compliance and patient safety.

SSI standardization

Jessica L. Swain, MBA, MLT (ASCP), CIC, Dartmouth-Hitchcock Senior Infection Preventionist,  leads the surgical site infection (SSI) prevention efforts working with perioperative leadership, nursing, surgeons and ancillary staff. This team updated SSI prevention bundles to meet best practice requirements to standardize perioperative patient care and reduce SSIs.

Dartmouth-Hitchcock, like most U.S. health systems and hospitals, has struggled to reduce SSIs and other HAIs during the pandemic, but the IP team has successfully increased compliance with documentation of the SSI prevention bundles. And while patient acuity increased between 2020 and 2021, there was no increase in SSI infections.

Swain also serves as the infection control standards and regulatory compliance expert to ensure continuous regulatory readiness throughout Dartmouth-Hitchcock, which was reaccredited by the Joint Commission in 2021 with accolades on infection control processes.

50% CLABSI decrease

Caitlin Adams Barker, MSN, RN, CIC is a Dartmouth-Hitchcock Senior Infection Preventionist and Nursing Assistant Clinical Instructor. She was Program Director for the APIC New England Chapter in 2020 and was elected Nominating and Awards Director Elect in 2021. APIC awarded her Fellow status (FAPIC) in recognition of her contributions to the profession.

Barker has simultaneously served as the IP representative for the COVID Incident Command team and led the central line associated blood stream infection (CLABSI) committee and associated work.

In 2021, Barker approved a central line insertion policy, which outlines the competency requirements and insertion protocol for providers who insert central lines. This is critical to ensuring provider competency for patient safety and reduced risk of infection following insertion. Barker’s work contributed to a 50% decrease in CLABSIs in 2021 as compared with 2020.

Safe IUC use

Erica Leonard, MSN, RN – BC, CNL, CIC is a preceptor for new IP staff and recently assumed the role of Nursing Assistant Clinical Instructor. She also participates in the Acute Care Council, Nursing COVID Resource Committee and leads the catheter associated urinary tract infection (CAUTI) committee.

Under Leonard’s leadership, the CAUTI committee has achieved the following:

• New “Take CAUTI On” campaign to encourage and reward nurses for timely removal of indwelling urinary catheters (IUCs)
• Updated IUC order-set to include selection of evidence-based indication and management plan for the IUC
• An online CAUTI Prevention Toolkit accessible to all staff
• Updated urine culture order to include indication to help prevent inappropriate culturing of urine
• Regular rounding on patients with IUCs to ensure IP bundle elements are being utilized
• Just in time education to nurses and providers whenever needed

Cameron Griffin, BS, MB (ASCP), CIC, Infection Preventionist, leads the C. difficile committee and participates in the Antimicrobial Stewardship Committee to prevent misuse/overuse of antimicrobials.

In 2021, Griffin and the C. difficile committee implemented several new initiatives to help stop transmission and reduce infections:

• A bare below the elbows policy, new cleaning and disinfection procedures, and nurse driven CDI protocol allowing nurses to order C. difficile testing based on new or worsening symptoms
• A diagnostic stewardship tool and best practice alert for patients on high-risk antibiotics with a history of C. difficile to prevent recurrence, along with prevention education for new nurses
• Investigation of the potential benefits of an updated testing algorithm with the intention of reduction in detection of C. difficile colonization and resulting inappropriate antibiotic treatment
• IP team collaboration with Environmental Services (EVS) leadership to ensure that EVS staff are trained in IP best practices, and that all cleaning and disinfection products are ideal for keeping patients and staff safe from transmission of potentially infectious organisms
Hand hygiene success

Carrie Silver, MSN, RN, CNOR, Infection Preventionist, leads the Hand Hygiene and Personal Protective Equipment Committee, and participates in work related to HAI prevention and COVID surveillance and reporting.

Throughout the pandemic, Silver has leveraged several hand hygiene technologies to improve compliance. These efforts include:

• Implementation of an electronic hand hygiene monitoring system used by over 2,500 employees and capturing over 30,000 hand hygiene events each day
• Use of a hand washing technology to train staff on the correct steps when performing hand hygiene, which has been rolled out to a variety of departments, including EVS and ambulatory clinics
• Updated training materials for use of hand hygiene direct observation collection software that allows staff to collect both hand hygiene and PPE data for analysis and reporting, along with virtual training sessions

Advanced analytics and reporting

Kathleen Stewart, MPH, is an embedded Quality Specialist on the IP team. Stewart functions in the role of data analytics and reporting and assists the team with project management, meeting facilitation, and use of data management tools.

Stewart has created compliance reports for everything from hand hygiene to infection prevention bundles, as well as dashboards for quality reporting and keeping goals on task. Stewart also has expertise in regulatory surveys and functioned as a survey coordinator during the 2021 Joint Commission survey.

Support across the board

Stephanie Casale, BSN, RN, Infection Preventionist, assists with day-to-day IP work, including CLABSI, CAUTI, C. difficile, and COVID surveillance and reporting.

Additionally, Casale has partnered with the IP team on projects to reinvigorate new employee orientation, hand hygiene education, and C. difficile mitigation strategies. She has also taken on the role of Inpatient Dialysis expert for which she has developed a tracer to ensure IP best practices are being followed in this area.

“The Dartmouth-Hitchcock Infection Prevention team is one of the hardest working teams that I have ever had the privilege of working with,” said Swain. “Although the work of the team has increased exponentially throughout the COVID-19 pandemic, each team member has continued to work toward hospital acquired infection reduction goals and improvement of patient safety and quality of care.”

A nationwide approach to IP standardization

As health systems continue to grow through mergers and acquisitions (M&A), leaders are challenged to unite clinical and operational stakeholders from across various hospitals in common goals and processes.

In 2016, Ascension, one of largest U.S. health systems, created a new system level position, Senior Director of IP, and hired Lisa Sturm for the role. Sturm was charged with building a system-wide IP program to connect and engage infection preventionists at 142 Ascension hospitals across 13 major markets and 19 states in the fight against healthcare acquired infections (HAIs). She took a “systems thinking” approach focused on data/analytics, prioritization and collaboration.

Data and analytics

Gaining a system-wide view of HAIs and then pinpointing opportunities for improvement requires a robust data set and analytics that some large health systems may not have. Rather than reinventing the wheel, Sturm worked with the Ascension’s analytics team to leverage the Centers for Disease Control and Prevention’s (CDC) National Healthcare Safety Network (NHSN) HAI tracking system.

Any hospital that requests payment from the Centers for Medicare and Medicare Services (CMS) must report HAIs to the NHSN database. Ascension’s analytics team has provisioning rights to all data submitted by the health system’s hospitals. This enabled them to develop dashboards at the national, market, hospital and in some cases unit level (e.g., ICU, NICU) to guide Sturm and her IP and quality colleagues in their efforts.

Prioritization

As Sturm states, successfully addressing infections from a system level can’t be done with a “shotgun” approach, rather, she needed a way to prioritize those facilities that had the greatest opportunity for improvements.

The NHSN features a cumulative attributable difference (CAD) calculator that allows users to perform this prioritization. With the tool Sturm can identify high rates for various types of HAIs (e.g., CLABSI, CAUTI, MRSA, C.diff, SSI) across Ascension’s hospitals to determine where it makes most sense to target interventions.

“Let’s say for example on a national level there were 50 central-line blood stream infections (CLABSI) across the health system in one month, but the standardized infection ratio (SIR) was within our benchmarks,” said Sturm. “With this calculator we can apply analytics to determine where most of these infections are occurring taking into account a number of factors. If one hospital had a high number of infections during that time - let’s say 10 – we could work with that hospital in a focused review to bring down the entire health system’s CLABSI SIR.”

Collaboration

With actionable analytics in hand, Sturm built an infrastructure to support collaboration among IP teams across the health system, which is comprised of about 160 IP staff members. She helped build an internal website and chat forum and set up a national IP community call that is regularly attended by more than 100 infection preventionists. 

With a “bird’s eye view” to HAIs across the health system, Sturm uses these calls to share best practices, offer IP teams resources on the system level, and connect teams with one another.

“For example, if there is an Ascension hospital in one market that has a high CLABSI rates but low CAUTI rates, and another hospital in a different market with low CLABSI rates and high  CAUTI rates, I use these calls to make the connection and encourage them to meet and share best practices with one another for mutual improvement,” said Sturm.

Sturm and her project manager records the calls and they share the recordings with attendees, along with her slide decks. Because call participants use the chat box feature to ask questions, Sturm saves these questions in a document, along with her answers, and sends this “chat box Q&A” to attendees, which was particularly helpful during COVID-19.

Trust

Sturm said trust is a critical component of the system-wide IP program’s success. Because IP teams are encouraged to be transparent with their challenges related to HAIs, they must trust that Sturm has their best interests at heart.

“They have to know that I have their backs, I’m not going to betray their transparency, but rather appreciate their challenges and honesty and will provide the support they need,” said Sturm. “I remind them every day that we are a family and work together for the common goal of reducing infections.”

Under Sturm’s leadership, Ascension has recorded decreases in multiple HAIs. To address high CLABSI rates, she led a multidisciplinary team that standardized the placement and care of lines, creating a guideline for best practices, established competencies, and partnered with frontline teams, resulting in a 38% reduction in CLABSI over a three-year period prior to the COVID-19 pandemic.

A united front against COVID-19

When COVID-19 hit the U.S. in early 2020, Sturm’s program enabled IPs from across Ascension to mount a standardized, effective and efficient response to the pandemic. The national IP community calls, which previously took place once per quarter, became weekly events where she would share updates with stakeholders from across all the hospitals and they would collaborate on solutions.

“We had all the core components in place for a nationwide IP response when COVID hit, we just had to flip the subject matter,” said Sturm. “The weekly calls became so popular that attendance grew beyond IP teams and out to other key stakeholders, including clinical leaders and staff members from various departments. We had hundreds of people on these calls at one point.” The calls continue to this day meeting bi-weekly providing real time updates on the COVID-19 response plan, as well as other IP updates. 

Next steps

It has been well documented and published that HAIs across the world increased in the face of the pandemic. Research and strategies are now in place at Ascension to address these increases, learn from the experience, and put into place reduction and prevention strategies for the future going forward. Sturm is confident that the infrastructure, teamwork and collaborative spirit that is already in place for Ascension’s Infection Prevention program will prime it for on-going success to endure not only this pandemic, but any future ones that may come along.

Competency-based training sets up hospital for COVID management success

The Centers for Disease Control and Prevention (CDC) has long supported state health departments in assessing infection prevention practices and guiding quality improvement activities in U.S. hospitals through its Infection Control Assessment Tools.¹

In late 2018, the IP team at Tampa General Hospital (TGH) in Tampa, Fla., invited the Florida Department of Health to conduct an infection control risk assessment survey of its facilities to identify and address any gaps in IP protocols and practices.

Coming out of the survey, the Florida Department of Health surveyors recom­mended TGH institute a competency-based training program around hand hygiene, disinfection (of equipment and the environment) and the proper donning and doffing of personal protective equipment (PPE).

“We had been performing education-based training for clinical staff for years around these three areas but didn’t always address the competency piece,” said Kimberly Atrubin, MPH, CIC, CPHQ, FAPIC, TGH’s Director of Infection Prevention. “With the addition of the annual competency-based training program, clinicians would be required to both learn the skills and demonstrate them.”

In early 2019, Atrubin and her nine-person team rolled out the complete training program to TGH’s clinical staff members, and the hand hygiene portion to non-clinical staff members, which comprised a total of about 8,200 individuals.

“It was a great back-to-basics initiative,” said Atrubin. “Our expectation was for everyone at TGH to know how to perform effective hand hygiene because it is not only good for our patients but for our community in general.”

“It’s astounding how TGH has built a culture that is so supportive of IP practices,” added Benjamin D. Galvan, MLS (ASCP), CIC, Infection Preventionist at TGH and a member of the APIC National Communications Committee. “Team members are more often than not willing to support IP practices and engage in education and competencies.”

When COVID hit

In early 2020, TGH’s IP team led the organization in renewing the hand hygiene, disinfection and PPE competencies. Any staff member who had been hired after the first round of competency training in early 2019 had to undergo this training upon hire so “by the time COVID hit, we knew everyone had gone through the training at least once,” explained Atrubin. “They had the skills, we just had to refresh them.”

Like most IP teams, the TGH team was flooded with an influx of staff questions and requests when COVID-19 began spreading throughout the U.S.

“I was expecting to get flooded with questions from clinical departments but surprised at the abundance of questions from non-clinical departments as well,” said Atrubin. “Every department wanted the IP team involved.”

Atrubin and her team took a “divide-and-conquer” approach to supporting both clinical and non-clinical staff members, with Atrubin leading efforts around in-patient workflows and another team member taking on ambulatory settings. “It really helped having a main point person to field inquiries and requests,” she commented.

At the same time, TGH’s Chief Quality Officer led a COVID Clinical Task Force with daily clinical team meetings, while the hospital’s Chief Operations Officer facilitated house-wide daily meetings for staff members across all departments. 

“It was great having those meetings in place because it became dedicated time where everybody heard the same questions and the same answers,” said Atrubin.

The IP team also established a webpage that housed the most current COVID resources for TGH. When there was a change in practice or protocol, TGH’s Chief Executive Officer would send out an email alerting staff members to the change.

“We really leaned on the fact that we were an academic medical center and made sure staff understood the science behind changes,” said Atrubin. “For example, we provided detailed information on the meaning behind PCR test results and what the results meant for patient isolation practices.”

“Now in our third surge of COVID, staff members are responding very efficiently,” said Galvan. “Much of our work in IP is encouraging clinical staff members and helping them feel confident that they can take care of patients safely because they have the training and can trust their skills.”

Extending IP into the community

In parallel with its internal efforts to combat COVID, TGH has provided IP support to the greater Tampa Bay community through its TGH Prevention Response Outreach (TPRO) program.

“At the time when COVID hit, our CEO and senior leadership recognized we needed to support the community,” said Atrubin, who is the TPRO Director. “We have a lot of community partners and they were coming to us asking for help and recommendations on the pandemic.”

Over the past two years, Atrubin and the TPRO team have worked with numerous Tampa Bay organizations on IP protocols, including the Tampa Bay Lightning hockey team, The Florida Aquarium, several museums and schools. Looking ahead, they plan to expand the program to address other areas in occupational health beyond COVID.

“The TPRO program was one factor that really drew me to the hospital because it is something that you don’t really see anywhere associated with an academic medical center,” said Galvan, who joined TGH in 2021. “The program aligns with APIC’s new vision and mission to advance infection prevention outside of healthcare and into the public domain where it needs to be.”

Monitoring and motivation drive 130% increase in hand hygiene compliance

Hand hygiene can help prevent the spread of infectious agents in healthcare facilities, but as the CDC points out, healthcare providers clean their hands, on average, less than half of the times they should.²

Seeking to better protect patients and staff from the spread of HAIs, St. Joseph Hospital in Savannah, Georgia launched an initiative to improve hand hygiene (HH) compliance. They selected and installed an electronic HH compliance monitoring system (CenTrak) in November 2019. Once pandemic-related hospitalizations surged in early 2020, the IP team knew compliance was crucial.

They understood the critical secret: their team must invest time into the process to achieve the greatest success. Emmitt Smith, RN, CIC, Infection Control Practitioner, who served as the dedicated team lead, engaged the technology, advocated for hand hygiene, remained open to ideas, and reinforced how data improves operations.

To garner greater support, Emmitt distributed hand-written letters to every high performer via the mail, highlighting how critical their work was and how proud the hospital was of their growing HH achievement. In addition to the encouraging letters shared, pizza parties for high compliance units motivated staff to compete and grow their pride in the HH project.

The efforts of Emmitt, the IP team, and each individual staff member resulted in a 130% increase in HH compliance. The compliance numbers are now consistently among the best in the nation and often as high as 90%. Furthermore, the facility’s cost of HAIs has dropped by more than $400,000 since reenergizing their HH compliance campaign.

Visual feedback and education results in 70% higher surface disinfection scores

While surface disinfection has been a long-term challenge in healthcare, the COVID-19 pandemic has made it even harder to maintain compliance. The CDC states in its 2020 annual National and State Healthcare-Associated Infections (HAI) Progress Report,

“The COVID-19 pandemic created a perfect storm for HAIs in healthcare settings. Many hospitals faced extraordinary circumstances that may have reduced the implementation of standard infection prevention and control (IPC) practices.”³

In 2021, the IP team at Hackensack University Hospital in Edison, N.J. sought to determine the effectiveness of adding a color additive (Kinnos Highlight) to bleach wipes, which provides immediate visual feedback to EVS staff on their cleaning effectiveness. The liquid blue indicator, when dispensed onto bleach disinfectant wipes, provides a temporarily visible bright blue trace to depict wiping surface coverage before fading away to clear in minutes. The IP team documented their work, which was published in the November 2021 edition of the American Journal of Infection Control (AJIC).⁴

“The advantage of adding a color additive to the bleach wipes is that it allows the person to see, in real-time, the areas that they have, or have not, cleaned,” Dr. Zuckerman added. “Making the invisible, visible will enable more efficient/effective cleaning at the time it is being performed and contribute to our overall infection prevention improvement efforts.”

Dr. Zuckerman and his team performed a prospective study from July 2021 to August 2021. During the control phase, routine terminal cleaning of isolation rooms was performed by EVS staff using standard bleach disinfectant wipes (Sani-Cloth Bleach Germicidal Disposable Wipe, PDI Healthcare). During the intervention phases, EVS staff were provided with the color additive (Kinnos Highlight) to combine with their standard bleach wipes. Disinfection quality was quantified through both fluorescent marking removal (Diversey VeriClean Fluorescent Marking Spray) and ATP bioluminescence assay (3M Clean-Trace Luminometer).

The results showed that use of the color additive on the bleach wipes improved fluorescent marking cleaning scores by 70% and ATP scores by 30% in just a few weeks. While the facility’s cleaning assessment scores varied significantly before addition of the colorant, after its addition they achieved 100% passing scores. 

“The pilot performed was a result of a shared decision-making process between environmental services and infection prevention,” said Dr. Zuckerman. “The recent COVID surge and staffing shortages has put further roll out of the product on temporary hold. In the short term, we hope to see an impact on EVS job satisfaction as they learn and recognize how their efforts contribute to patient safety.”

Scope storage initiative drives greater compliance and safety

Effective scope management and storage have been hot topics in infection control, with several highly publicized infection outbreaks tied back to contaminated scopes. The U.S. Food and Drug Administration (FDA) and industry associations continue to publish new guidance on scope handling and reprocessing in light of these events.

As an organization dedicated to patient safety, infection prevention, and quality improvement, the safe and effective reprocessing and storage of endoscopes has been a high priority at The Queen’s Health Systems in Honolulu, Hawaii.

“The drying of endoscopes is important to decrease the risk of microbial growth while they are stored and before the next use,” said Julian Martinez, CRCST, CIS, CHL, Coordinator, Sterilization & Disinfection, Infection Prevention & Control, The Queen’s Health Systems. “Drying at the right temperature and humidity promotes optimal scope readiness. Proper storage of scopes is important to protect them from damage, decrease the potential for microbial growth, and ensure monitoring of its use is managed.”

The Queen’s Health Vice President of Surgical Services was the first to acknowledge that the health system’s scope management processes and equipment at the time did not meet industry standards: AAMI ST91:2015 and SGNA:2018. In particular, the old scope cabinets in place were insufficient and could not support the organization’s growing demands.

“With the old cabinets being conventional and outdated, the issue of compliance was not having the endoscopes stored properly in a secured cabinet, and not allowing adequate space around the scope for optimal drying capabilities,” Martinez explained.

The VP engaged the Infection Prevention (IP) department, and they collaborated on a solution. Because new scope storage cabinets would be a capital expenditure, the VP and IP team built a case for why their request should be at the top of the health system’s priority list. They also developed a list of required cabinet features to meet compliance standards which included drying capability, humidity control, and ability to store longer scopes.

“Our organization was committed to making a move to comply with society guidelines for temperature, humidity, and the drying of the inner channels,” said Martinez. “The purchase of these cabinets was going to help us improve on compliance, and leadership at The Queen’s Health Systems was very supportive during the process.”

Leadership acknowledged the importance of scope drying and storage for the safety of the health system’s patients and approved the cabinet purchase (Clinical Choice ScopeVault cabinets). According to Martinez, the cabinets have helped The Queen’s Health Systems improve compliance in several ways:

“ScopeVault cabinets helped us achieve appropriate storage standards by not having the scopes touch the bottom of the cabinet and by circulating HEPA filtered air within the cabinet space and through the scope channels to ensure the scopes remain dry. These improvements have provided greater patient safety by providing endoscopes that have gone through the proper disinfection process and are appropriately dried. We can easily store endoscopes that previously would not fit in the older cabinets with the space-saving design.”

Martinez added, “by utilizing an endoscope cabinet that can provide security and proper drying of the channels, it ensures that we are providing the best possible care to our patients.”

Supporting those who protect caregivers and patients

Like physicians, nurses and other healthcare workers, IPs have been working nights, weekends and holidays under intense pressure throughout the pandemic. But unlike those on the front lines, it is not generally known what IPs are doing behind the scenes to protect patients and their caregivers from harm. Their efforts are monumental and APIC has been doing what it can to help its members take care of themselves while they fight the fight.

“It’s hard to find time to unplug when you are working long hours, buried in email and your phone is ringing off the hook, but we have to. If we don’t, we will burn out,” said Dickey. 

Despite the unprecedented challenges IPs have faced over the past two years, APIC members continue to plan for the future of the profession.

“We are in the same boat as all of the other healthcare fields with the need to fill the pipeline with new talent to replace those who are retiring,” said Dickey. “We’ve had volunteers continue to do good work to figure out what APIC’s future will look like. I want to honor those people who have carved out time to continue to help move us forward as a profession.”

References
1. Infection Control Assessment Tools, CDC, https://www.cdc.gov/hai/prevent/infection-control-assessment-tools.html
2. Clean Hands Count for Safe Healthcare, CDC, https://www.cdc.gov/patientsafety/features/clean-hands-count.html
3. 2020 National and State Healthcare-Associated Infections (HAI) Progress Report, CDC, October 2021, https://arpsp.cdc.gov/profile/national-progress/united-states
4. Tyan K, Zuckerman JM, Cutler C, Modupe K, Ray D, Marmolejo L, Kang J. A multiphase intervention of novel color additive for bleach disinfectant wipes improves thoroughness of cleaning in an academic medical center. Am J Infect Control. 2021 Nov 16:S0196-6553(21)00738-0. doi: 10.1016/j.ajic.2021.11.002. Epub ahead of print. PMID: 34793887.